72 Wise Pattern Breast Reduction

Francesco M. Egro and Kenneth C. Shestak

Abstract

Wise pattern breast reduction is an optimal technique to improve the functional and aesthetic impairment caused by moderate to severe macromastia. This technique allows repositioning of the nipple-areolar complex, removal of excess parenchyma, and skin redraping to fit the new breast shape and size. This book chapter reviews the preoperative, intraoperative, and postoperative steps to obtain optimal aesthetic results in patient undergoing a Wise pattern breast reduction to treat macromastia.

Breast reduction – reduction mammaplasty – reduction mammoplasty – Wise – inverted-T – inferior pedicle – breast contour – breast aesthetics – macromastia

72 Wise Pattern Breast Reduction

Key Points

Wise pattern breast reduction is an optimal technique to improve the functional and aesthetic impairment caused by moderate to severe macromastia.
This technique allows repositioning of the nipple-areolar complex (NAC), removal of excess parenchyma, and skin redraping to fit the new breast shape and size.
Breast reduction requires careful patient selection, planning, and surgical delivery for optimal aesthetic results.

72.1 Preoperative Steps

72.1.1 Analysis

The first step is to understand the patient’s expectations and assess whether they can be met.
A thorough history should focus on personal or family history of breast cancer, prior breast surgery, and current and desired breast size.
A detailed examination includes assessment of breast symmetry, “footprint,” size, shape, degree of ptosis, skin quality and elasticity, presence of axillary tissue, inframammary fold (IMF) level, and NAC size and shape.

72.1.2 Markings

In the standing position, the breasts are marked including midline, breast meridian, midline, IMF, Pitanguy’s point, and new nipple position.
An inverted “V” is drawn from the nipple position with the limbs measuring approximately 9 cm with the degree of divergence based on the amount of resection planned.
The outline of the new areola (4 cm diameter) is drawn with the upper aspect of the areola marked 2 cm above Pitanguy’s point.
The mid breast meridian is transposed to the lower chest area marking the mid portion of the inframammary incision (outlined 2 cm above the IMF).
Medial and lateral limbs are extended to join the inframammary incision markings. Markings of the Wise pattern are shown in Fig. 72.1.
A 7-cm pyramidal pedicle is marked.

Fig. 72.1 Preoperative marking of a Wise pattern breast reduction.

72.2 Operative Steps

A description of the key operative steps are shown in Video 72.1.

72.2.1 NAC and Pedicle Delineation

Inject 1:1 mixture of 0.5% bupivacaine and 1.0% xylocaine with 1/100,000 of epinephrine into the deep dermis and superficial subcutaneous adipose layer of each breast (not into parenchyma) for superficial vasoconstriction and extended immediate postoperative analgesia. Approximately 10 cc is placed on each side.
The new NAC is marked using a 42-mm cookie cutter.
Incisions are made along the markings to delineate the NAC and the pedicle.
The pedicle and NAC are de-epithelialized using a #10 scalpel.

72.2.2 Medial Dissection

Dissection is started medial to the pedicle by performing a beveling dissection to preserve perforators from the internal mammary system (Fig. 72.2).
The dissection is then initiated at the level of the junction of the deep subcutaneous tissue anterior breast fascia to raise a flap approximately 1 cm in thickness and is deepened through the breast capsule 2 cm from the medial edge of the pedicle.
The inferior dissection of the medial triangle is made by beveling cephalad. The dissection is deepened through the superficial fascia system 2 cm above the incision to preserve the IMF.
The medial triangle is then resected.

Fig. 72.2 Vascular anatomy of the breast highlighting the internal mammary perforators.
(Reproduced with permission from Nahai F. The Art of Aesthetic Surgery. 2nd ed. Thieme; 2011.)